A WORD TO OUR PATIENTS ABOUT MEDICARE AND WELLNESS CARE

Transcription

1 A WORD TO OUR PATIENTS ABOUT MEDICARE AND WELLNESS CARE Dear Patient, Your appointment for your Medicare Annual Wellness Visit is scheduled for. We want you to receive wellness care health care that may lower your risk of illness or injury. Medicare pays for some wellness care, but it does not pay for all the wellness care you might need. We want you to know about your Medicare benefits and how we can help you get the most from them. The term physical is often used to describe wellness care. But Medicare does not pay for a traditional, head-to-toe physical. Medicare does pay for a wellness visit once a year to identify health risks and develop a plan to keep you healthy. At your wellness visit, our health care team will: Review your complete medical history Complete screenings to detect depression, risk for falling and other problems Complete a limited physical exam to check your blood pressure, weight, vision and other things depending on your age, gender and level of activity Review your risk factors Develop a personalized prevention plan to keep you healthy Recommend other wellness services and healthy lifestyle changes. In order to prepare for your upcoming annual wellness visit, please complete the information included in this packet and bring it with you to your visit. Also, review the attached immunization list. If you have received any immunizations that are not listed, please list them. Please return these forms to our receptionist at check in on the day of your Annual Wellness Visit. Medicare is very specific about what the Annual Wellness Visit includes and excludes. A wellness visit does not address new or existing health problems. That would be a separate service and requires a longer appointment. Please let our scheduling staff know if you need the medical provider s help with a health problem, a medication refill or something else. We may need to schedule a separate appointment. A separate charge applies to these services, whether provided on the same date or a different date than the wellness visit. We hope to help you get the most from your Medicare wellness benefits. Please contact our office with any questions. Warmest regards, Adam A. Brunson, MD

2 Name: Date: Date of Birth: Medicare Annual Wellness Visit Health Risk Assessment Please complete this checklist prior to seeing your medical provider. Your answers will help you receive the best health care possible. General Health 1. In general, how would you rate your overall health? Excellent Very good Good Fair Poor 2. Compared to one year ago, how would you rate your current overall health? Much better Somewhat better About the same Somewhat worse Much worse 3. How many hours of sleep do you usually get each night? More than 8 hours 6-8 hours 4-5 hours Less than 4 hours 4. How often do you feel unusually tired?, rarely Often Always 5. During the past year, how much bodily pain have you generally had? No pain Very mild pain Mild pain Moderate pain Severe pain Physical Activity 6. How many days a week do you usually exercise? days per week 7. On days when you exercise, for how long do you usually exercise? minutes per day 8. How intense is your typical exercise? Light (like slow walking) Moderate (like brisk walking) Heavy (like jogging) Very heavy (like sprinting) I do not exercise Nutrition 9. On a typical day, how many servings of fruits and/or vegetables do you eat? (1 serving = 1 cup fresh vegetables, ½ cup cooked vegetables or 1 medium piece of fruit) servings per day 10. On a typical day, how many servings of high fiber or whole grain foods do you eat? (1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high fiber ready to eat cereal or ½ cup cooked cereal, brown rice or whole wheat pasta) servings per day 11. On a typical day, how many servings of fired or high-fat foods do you eat? (examples include fried chicken, fried fish, bacon, French fries, potato chips, creamy salad dressings or mayonnaise) servings per day

3 12. On a typical day, how many caffeinated drinks (coffee, tea, soda) do you drink? drinks per day 13. On a typical day, how many 8 oz. glasses of water do you drink? glasses per day Oral Health 14. How would you describe the condition of your mouth and teeth (including false teeth or dentures)? Excellent Very good Good Fair Poor 15. How often do you brush your teeth and/or dentures? At least once daily Most days of the week Seldom 16. How often do you floss your teeth? At least once daily Most days of the week Seldom Not applicable 17. Do you visit the dentist regularly? Functional Status 18. Do you need the help of another person with your personal care needs such as eating, bathing, dressing, using the toilet or getting around the house? 19. Do you need help with using the telephone? 20. Do you need help with shopping for groceries or clothes? 21. Do you need help with preparing meals? 22. Do you need help with housekeeping? 23. Do you need help with laundry? 24. Do you need help getting to places out of walking distance? (For example, traveling alone on buses or taxis, or driving your own car?) 25. Do you need help with taking your medications? 26. Do you need help with managing your money? 27. Are you having difficulties driving your car? Yes, often No Not applicable; I do not drive a car 28. Do you have any hearing problems? 29. Do others complain about your hearing? Safety Screening 30. Have you fallen in the past year? 31. Do you feel unsteady when you walk or get dizzy when you stand up? 32. Do you have loose rugs/slippery floors in your home? 33. Are grab bars present in the bathroom? 34. Are handrails present on the stairs? N/A

4 35. Is there obtrusive furniture or clutter in your home? 36. Is there poor lighting in your home? 37. Do you always wear your seatbelt when you are in the car? 38. Do you ever drive after drinking alcohol, or ride with a driver who has been drinking? 39. Is the hot water temperature set below 120 degrees? 40. Do you have functional smoke detectors in your home? 41. Do you protect yourself from the sun when you are outdoors? Social History 42. Please describe your home environment. Private home Assisted living Other: 43. How many people live in your home? persons 44. What is your marital status? Married Single Divorced Separated Widowed 45. Are you sexually active? Yes, with a monogamous partner Yes, with multiple partners No, not currently sexually active 46. My sexual partners are? Male Female Male and female Not applicable 47. Are you a smoker? smoked Former smoker Quit date: Yes, and I might quit Yes, but I am not ready to quit 48. Do you use a smokeless tobacco product? 49. During an average week, how many drinks of wine, beer, or other alcoholic beverages do you usually have? 10 or more drinks per week 6-9 drinks per week 2-5 drinks per week One drink or less per week No alcohol at all 50. Do you use street drugs? Prior use Daily Occasionally Mental Health 51. Over the past two weeks, how often have you had little interest or pleasure in doing things? Several days More than half the days Nearly every day 52. Over the past two weeks, how often have you felt down, depressed or hopeless? Several days More than half the days Nearly every day

5 53. Over the past two weeks, how often have you felt nervous, anxious or on edge? Several days More than half the days Nearly every day 54. How often is stress/anger a problem for you? or rarely Often Always 55. How well do you handle the stress/anger in your life? I m usually able to cope effectively At times I have problems coping I often have problems coping 56. Over the past two weeks, has your emotional health limited your social activities with family, friends, neighbors, or groups? Slightly Moderately Quite a bit Extremely 57. How often do you get the social and emotional support you need? Always Usually Rarely End of life planning 58. Do you have a do not resuscitate order? 59. Do you have a durable power of attorney? 60. Do you have a living will or advance directive? 61. Have you discussed your wishes with your family?

6 Patient Name: DOB: Review of Body Systems: Check all symptoms/problems that you are currently experiencing Constitutional Chills Excessive fatigue Fever Night sweats Weight gain (unintentional) Weight loss (unintentional) Eyes Loss of vision Blurry vision Eye drainage Eye pain Red eye Itchy eyes Spots before your eyes Glasses/contact lenses Ears, Nose & Throat Loss of hearing Ringing in the ears Ear pain Frequent runny nose Frequent nose bleeds Nasal congestion Bleeding gums Loss of smell Loss of voice Sore throat Sore tongue Tooth pain Dentures Hearing aids Cardiovascular Chest pain or discomfort Swollen ankles/feet Fainting spells Irregular heart beat Fast heart beat Leg/calf pain with walking Dizziness Shortness of breath when lying flat Varicose veins Respiratory Recent cough Chronic cough Coughing up blood Shortness of breath Wheezing Exposure to TB Gastrointestinal Difficulty swallowing Stomach/abdomen pain Loss of appetite Bloating Constipation Diarrhea Gastrointestinal (continued) Frequent heartburn/acid reflux Nausea Vomiting Vomiting blood Bloody stools Black stools Hemorrhoids Change in appearance of stool Genitourinary Pain with urination Blood in urine Leakage of urine Waking up to urinate at night Frequent need to urinate Change in urine stream Genital sores/rashes Pelvic pain Frequent urinary infections Male Only Difficulty with erections Lump on testicle Painful erections Penile discharge Female Only Painful intercourse Bleeding after intercourse PMS (premenstrual tension) Heavy periods Frequent periods Infrequent periods Irregular periods Painful periods Vaginal discharge Vaginal itching Menopausal Currently using birth control Currently/possibly pregnant Currently breastfeeding Musculoskeletal Painful joints Stiff joints Joint swelling Red, hot, tender joints Back pain Neck pain Muscle pain Skin/Breast Acne Changing/new moles Dry skin Nail changes Jaundice Itching Rash Skin/Breast (continued) Warts Breast lump Breast skin changes Breast tenderness Nipple discharge Neurologic Loss of balance Dizziness Frequent headaches Memory loss Numbness/tingling Seizures/convulsions Tremors Vertigo Weakness Hematologic/Lymphatic Excessive bleeding Increased bruising History of blood transfusion Enlarged lymph nodes/glands Endocrine Enlarging hands/feet Hair loss Heat intolerance Cold intolerance Excessive hair growth Hot flashes Increased skin pigmentation Infertility Excessive thirst Excessive sweating Excessive hunger Allergic/Immunologic Allergies/hayfever Hives Frequent colds/sinus infections Immune system disorder Psychiatric Anxiety Depression Crying spells Mood swings Feeling stressed Loss of interest in pleasurable activities Sadness Poor concentration Difficulty sleeping Sleeping too much Thoughts of suicide

7 Patient Name: DOB: Medication list Name of Medication Dosage Directions Other providers participating in your healthcare Name of Provider Specialty of Provider Type of Care Date of Last Visit Eye doctor, if applicable Dentist, if applicable Gynecologist, if applicable Hospitalizations within last three years Reason for Hospital Visit Facility Attending Physician Date Do you have any health improvement opportunities or medical concerns you would like to address?